NCLEX: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

Health Promotion and Maintenance; Nursing Care of the Childbearing Family: THE NEWBORN INFANT

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

VIII. CLASSIFICATION OF INFANTS BY WEIGHT AND GESTATIONAL AGE

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

A. Terminology

1. Preterm, or premature—37 weeks’ gestation or less (usually 2500 gm [5 lb] or less).

2. Term—38 to 42 weeks’ gestation.

3. Postterm—over 42 weeks.

4. Postmature—gestation greater than 42 weeks.

5. Appropriate for gestational age (AGA)—for each week of gestation, there is a normal range of expected weight (between 10th and 90th percentile).

a. Term infants weighing 2500 gm or more are usually mature in physiological functions.

b. If respiratory distress occurs, it is usually related to meconium aspiration syndrome.

6. SGA or dysmature—weight falls below normal range for age (<10th percentile).

a. Preeclampsia.

b. Malnutrition.

c. Smoking.

d. Placental insufficiency.

e. Alcohol syndrome.

f. Rubella.

g. Syphilis.

h. Multifetal gestation (twins, etc.).

i. Genetic.

j. Cocaine abuse.

7. LGA—above expected weight for age (>90th percentile). Note: If preterm, at risk for RDS. If postterm, at risk for aspiration and sudden intrauterine death.

a. Etiology:

  • Maternal diabetes or prediabetes.
  • Maternal weight gain over 35 lb.
  • Maternal obesity.
  • Genetic.

b. Associated problems:

  • Hypoglycemia.
  • Hypocalcemia.
  • Hyperbilirubinemia.
  • Birth injury (e.g., fractures, Erb-Duchenne paralysis).

Health Promotion and Maintenance; Nursing Care of the Childbearing Family

B. Estimation of gestational age—planning appropriate care for the newborn requires accurate assessment to differentiate between preterm and term infants. PRETERM INFANT—Born at 37 weeks of gestation or less.

A. Pathophysiology—anatomical and physiological immaturity of body systems compromises ability to adapt to extrauterine environment and independent life.

1. Interference with protective functions

a. Temperature regulation—unstable, due to:

  • Lack of subcutaneous fat.
  • Large body surface area in proportion to body weight.
  • Small muscle mass.
  • Absent sweat or shiver responses.
  • Poor capillary response to changes in environmental temperature.

b. Resistance to infection—low, due to:

  • Lack of immune bodies from mother (these cross placenta late in pregnancy).
  • Inability to produce own immune bodies (immature liver).
  • Poor WBC response to infection.

c. Immature liver

  • Inability to conjugate bilirubin liberated by normal breakdown of RBCs → increased susceptibility to hyperbilirubinemia and kernicterus.
  • Immature production of clotting factors and immune globulins.
  • Inadequate glucose stores → increased susceptibility to hypoglycemia.

2. Interference with elimination: immature renal function—unable to concentrate urine → precarious fluid-electrolyte balance.

3. Interference with sensory-perceptual functions: CNS—immature → weak or absent reflexes and fluctuating primitive control of vital functions.

B. Etiology: often unknown; preterm labor.

1. Iatrogenic—EDD miscalculated for repeat cesarean birth (rare).

2. Placental factors

a. Placenta previa.

b. Abruptio placentae.

c. Placental insufficiency.

3. Uterine factors

a. Incompetent cervix.

b. Overdistention (multifetal gestation, polyhydramnios).

c. Anomalies (e.g., myomas).

4. Fetal factors

a. Malformations.

b. Infections (rubella, toxoplasmosis, HIV-positive status, AIDS, cytomegalic inclusion disease).

c. Multifetal gestations (twins, triplets).

5. Maternal factors

a. Severe physical or emotional trauma.

b. Coexisting disorders (preeclampsia, hypertension, heart disease, diabetes, malnutrition).

c. Infections (streptococcus, syphilis, bacterial vaginosis, pyelonephritis, pneumonia, influenza, leukemia, UTI).

6. Miscellaneous factors

a. Close frequency of pregnancies.

b. Advanced maternal age.

c. Heavy smoking.

d. High-altitude environment.

e. Cocaine use.

C. Factors influencing survival:

1. Gestational age.

2. Lung maturity.

3. Anomalies.

4. Size.

D. Causes of mortality (in order of frequency):

1. Abnormal pulmonary ventilation.

2. Infection.

a. Pneumonia.

b. Septicemia.

c. Diarrhea.

d. Meningitis.

3. Intracranial hemorrhage.

4. Congenital defects.

E. Disorders affecting fluid-gas transport: RDS

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Pathophysiology—insufficient pulmonary surfactant (lecithin) and insufficient number/maturity of alveoli predispose to atelectasis; alveolar ducts and terminal bronchi become lined with fibrous, glossy membrane.

2. Etiology:

a. Primarily associated with prematurity.

b. Other predisposing factors:

  • Fetal hypoxia—due to decreased placental perfusion secondary to maternal bleeding (e.g., abruptio placentae) or hypotension.
  • Birth asphyxia.
  • Postnatal hypothermia, metabolic acidosis, or hypotension.

3. Factors protecting neonate from RDS:

a. Chronic fetal stress—due to maternal hypertension, preeclampsia, or heroin addiction.

b. PROM.

c. Maternal steroid ingestion (e.g., betamethasone).

d. Low-grade chorioamnionitis.

4. Assessment:

a. Usually appears during first or second day after birth.

b. Signs of respiratory distress:

  • Nasal flaring.
  • Expiratory grunt.
  • Sternal retractions.
  • Tachypnea (60 breaths/min or more).
  • Cyanosis—central.
  • Increasing number and length of apneic episodes.
  • Increasing exhaustion.

c. Respiratory acidosis—due to hypercapnea and rising [latex] CO_2 [\latex] level.

d. Metabolic acidosis—due to increased lactic acid levels and falling pH.

5. Analysis/nursing diagnosis:

a. Impaired gas exchange related to lack of pulmonary surfactant secondary to preterm birth, intrapartum stress and hypoxia, infection, postnatal hypothermia, metabolic acidosis, or hypotension.

b. Altered nutrition, less than body requirements, related to poor feeding secondary to respiratory distress, ↑ caloric demand.

6. Nursing care plan/implementation:

a. Goal: reduce metabolic acidosis, increase oxygenation, support respiratory efforts.

  • Ensure warmth (isolette at 97.6°F).
  • Warmed, humidified [latex] O_2 [\latex] at lowest concentration required to relieve cyanosis, through hood, nasal prongs, or endotracheal tube.
  • Monitor continuous positive airway pressure (CPAP)—oxygen–air mixture administered under pressure during inhalation and exhalation to maintain alveolar patency.
  • Position: side-lying or supine with neck slightly extended (“sniffing” position); arms at sides.
  • Suction prn with bulb syringe—for excessive mucus.

b. Goal: modify care for infant with endotracheal tube.

  • Disconnect tubing at adapter.
  • Inject 0.5 mL sterile normal saline (may be omitted).
  • Insert sterile suction tube, start suction, rotate tube, withdraw.
  • Suction up to 5 seconds.
  • Ventilate with bag and mask during procedure.
  • Reconnect tubing securely to adapter.
  • Auscultate for breath sounds and pulse.

c. Goal: maintain nutrition/hydration.

  • Administer fluids, electrolytes, calories, vitamins, minerals PO or IV, as ordered.
  • I&O.

d. Goal: prevent secondary infections.

  • Strict aseptic technique.
  • Hand washing.

e. Goal: emotional support of infant.

  • Gentle touching.
  • Soft voices.
  • Eye contact.
  • Rocking.

f. Goal: emotional support of parents.

  • Keep informed of status and progess.
  • Encourage contact with infant—to promote bonding, understanding of treatment.

g. Goal: minimize possibility of iatrogenic disorders associated with oxygen therapy (see F. and G., below).

7. Evaluation/outcome criteria:

a. Respiratory distress treated successfully; infant breathes without assistance.

b. Infant completes successful transition to extrauterine life.

F. Iatrogenic (oxygen toxicity) disorders: retinopathy of prematurity

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Pathophysiology—intraretinal hemorrhage → fibrosis → retinal detachment → loss of vision.

2. Etiology—prolonged exposure to high concentrations of oxygen.

3. Assessment—only perceptible retinal change is vasoconstriction. Note: Arterial blood gas ([latex] PaO_2 [\latex]) readings less than 50 or more than 80 mm Hg.

4. Nursing care plan/implementation: Goal: prevent disorder. Maintain [latex] PaO_2 [\latex] of 50 to 70 mm Hg.

5. Evaluation/outcome criteria:

a. Successful recovery from respiratory distress.

b. No evidence of retinopathy.

G. Iatrogenic (oxygen toxicity) disorders: bronchopulmonary dysplasia (BPD)

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Pathophysiology—damage to alveolar cells result in focal emphysema.

2. Etiology—positive-pressure ventilation (CPAP and positive end-expiratory pressure [PEEP]) and prolonged administration of high concentrations of oxygen.

3. Assessment—monitor for signs of:

a. Tachypnea.

b. Increased respiratory effort.

c. Respiratory distress.

4. Nursing care plan/implementation: Goal: prevent disorder.

a. Use of positive-pressure devices.

b. Maintain oxygen concentration below 80%.

c. Supportive care.

d. Wean off ventilator, as possible.

5. Evaluation/outcome criteria:

a. Successful recovery from respiratory distress.

b. No evidence of disorder.

H. Intraventricular hemorrhage

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Pathophysiology—rupture of thin, fragile capillary walls within ventricles of the brain (more common in preterm).

2. Etiology:

a. Hypoxia.

b. Respiratory distress.

c. Birth trauma.

d. Birth asphyxia.

e. Hypercapnia.

3. Assessment:

a. Hypotonia.

b. Lethargy.

c. Hypothermia.

d. Bradycardia.

e. Bulging fontanels.

f. Respiratory distress or apnea.

g. Seizures.

h. Cry: high-pitched whining.

4. Nursing care plan/implementation: Goal: supportive care to promote healing.

a. Monitor vital signs.

b. Maintain thermal stability.

c. Ensure adequate oxygenation (may be placed on CPAP).

5. Evaluation/outcome criteria:

a. Condition stable, all assessment findings within normal limits.

b. No evidence of residual damage.

I. Disorders affecting nutrition

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Pathophysiology—underdeveloped feeding abilities, small stomach capacity, immature enzyme system, fat intolerance.

2. Etiology—immature body systems associated with preterm birth.

3. Assessment:

a. Weak suck, swallow, gag reflexes—tendency to aspiration.

b. Signs of malabsorption and fat intolerance (abdominal distention, diarrhea, weight loss, or failure to gain weight).

c. Signs of vitamin E deficiency (edema, anemia).

4. Analysis/nursing diagnosis:

a. Altered nutrition, less than body requirements, related to poor feeding reflexes, reduced stomach capacity, inability to absorb needed nutrients.

b. Impaired gas exchange related to aspiration.

5. Nursing care plan/implementation: Goal:
maintain/increase nutrition.

a. Frequent, small feedings—to avoid exceeding stomach capacity, facilitate digestion.

b. Frequent “burping” during feeding—to avoid regurgitation/aspiration.

c. Supplement vitamin E (alpha-tocopherol) intake, as ordered, in infants who are formulafed. (Note: intake adequate in infants who are breastfed.) Vitamin E actions:

  • Antioxidant.
  • Maintains structure and function of smooth, skeletal, and cardiac muscle.
  • Maintains structure and function of vascular tissue, liver, and RBC integrity.
  • Coenzyme in tissue respiration.
  • Treatment for malnutrition with macrocytic anemia.

d. Encourage parent/family participation.

6. Evaluation/outcome criteria:

a. Feeds well without regurgitation/aspiration.

b. Maintains/gains weight.

c. No evidence of malabsorption, vitamin deficiency.

J. Disorders affecting nutrition/elimination: necrotizing enterocolitis (NEC)

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Pathophysiology—intestinal thrombosis, infarction, auto-digestion of mucosal lining, and necrotic lesions; incidence increased in preterm.

2. Etiology—intestinal ischemia, due to blood shunt to brain and heart in response to:

a. Fetal distress.

b. Fetal/neonatal asphyxia.

c. Neonatal shock.

d. After birth, may result from:

  • Low cardiac output.
  • Infusion of hyperosmolar solutions.

e. Complicated by action of enteric bacteria on damaged intestine.

3. Assessment—early identification is vital.

a. Abdominal distention or erythema, or both.

b. Poor feeding, vomiting.

c. Blood in stool.

d. Systemic signs associated with sepsis that may need temporary colostomy or iliostomy:

  • Lethargy or irritability.
  • Hypothermia.
  • Labored respirations or apnea.
  • Cardiovascular collapse.

e. Medical diagnosis:

  • Increased gastric residual.
  • X-ray shows ileus, air in bowel wall.

4. Analysis/nursing diagnosis:

a. Altered nutrition, less than body requirements, related to inability to tolerate oral feedings, and gastrointestinal dysfunction secondary to ischemia, thrombosis, or necrosis.

b. Constipation related to paralytic ileus with stasis; diarrhea related to water loss.

c. High risk for injury related to infection, thrombosis, metabolic alterations (acidosis, osmotic diuresis, dehydration, hyperglycemia) due to parenteral nutrition.

d. Altered parenting related to physiological compromise and prolonged hospitalization.

e. Impaired skin integrity when colostomy is necessary.

5. Nursing care plan/implementation:

a. Goal: supportive care.

  • Rest GI tract: no oral intake—to achieve gastric decompression.
  • IV fluids, as ordered—to maintain hydration.

b. Goal: prevent infection. Administer antibiotics, as ordered.

c. Goal: prevent trauma to skin surrounding stoma.

6. Evaluation/outcome criteria:

a. Tolerates oral feedings.

b. Demonstrates weight gain.

c. Normal stool pattern.

d. Parents are accepting and knowledgeable about care of infant.

POSTTERM INFANT—Over 42 weeks of gestation.

A. General aspects

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Labor may be hazardous for mother and fetus because:

a. Large size of infant contributes to cephalopelvic disproportion; obtain estimate of fetal weight (EFW) by ultrasound.

b. Placental insufficiency → fetal hypoxia; diagnosis by:

  • Contraction stress test.
  • Nonstress test
  • Amniotic fluid index (AFI).

c. Meconium passage (common physiological response) increases chance of meconium aspiration.

B. Assessment:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. If post-mature skin: dry, wrinkled—due to metabolism of fat and glycogen reserves to meet in utero energy needs.

2. Long limbs, fingernails, and toenails—due to continued growth in utero.

3. Lanugo and vernix—absent.

4. Expression: wide-eyed, alert—probably due to chronic hypoxia (oxygen hunger).

5. Placenta—signs of aging.

C. Analysis/nursing diagnosis: High risk for injury related to high incidence of morbidity and mortality due to dystocia or hypoxia.

D. Nursing care plan/implementation:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. During labor:

a. Goal: emotional support of mother—may require cesarean birth due to CPD or fetal distress.

b. Goal: continuous electronic monitoring of FHR. Report late decelerations immediately (indicate fetal distress).

2. After birth:

a. Goal: if born vaginally, prompt identification of birth injuries, respiratory distress. Continual observation.

b. Goal: early identification/treatment of emerging signs of complications.

  • Hypoglycemia—Dextrostix readings and behavior.
  • Administer oral or intravenous glucose, as ordered.

E. Evaluation/outcome criterion: successful transition to extrauterine life (all assessment findings within normal limits).

Health Promotion and Maintenance; Nursing Care of the Childbearing Family: Congenital Disorders

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

I. GENERAL OVERVIEW: Genetic abnormalities and environmental insults often lead to congenital disorders of the newborn. Successful transition to independent extrauterine life may pose a major challenge to infants compromised by anatomical or physiological disorders. Knowledge regarding the implications of the neonate’s structural or metabolic problems enables the nurse to identify early signs of health problems and to plan, provide, and evaluate appropriate outcome-directed care to safeguard the status of the infant with a congenital disorder.

II. DISORDERS AFFECTING FLUID-GAS TRANSPORT: congenital heart disease

A. Pathophysiology—altered hemodynamics, due to persistent fetal circulation or structural abnormalities.

1. Acyanotic defects—no mixing of blood in the systemic circulation.

a. Patent ductus arteriosus.

b. Atrial septal defect.

c. Ventriclar septal defect.

d. Coarctation of the aorta.

2. Cyanotic defects—unoxygenated blood enters systemic circulation.

a. Tetralogy of Fallot.

b. Transposition of the great vessels.

B. Etiology—unknown. Associated with maternal:

1. Prenatal viral disease (e.g., rubella, coxsackievirus).

2. Malnutrition; alcoholism.

3. Diabetes (poorly controlled).

4. Ingestion of lithium salts.

C. Assessment:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Patent ductus arteriosus (see Fig. 5.5, p. 278).

a. Characteristic machine murmur, mid to upper left sternal border (cardiomegaly); persists throughout systole and most of diastole; associated with a “thrill.”

b. Widened pulse pressure.

c. Bounding pulse, tachycardia, “gallop” rhythm.

2. Atrial septal defect.

a. Characteristic crescendo-decrescendo systolic ejection murmur.

b. Fixed [latex] S_2 [\latex] splitting.

c. Dyspnea, fatigue on normal activity.

d. Medical diagnosis—cardiac catheterization, x-ray.

3. Ventricular septal defect.

a. Loud, harsh, pansystolic murmur; heard best at left lower sternal border; radiates throughout precordium. (Note: may be absent—due to high pulmonary vascular resistance → equalization of interventricular pressure.)

b. Medical diagnosis—cardiac catheterization, ECG, chest x-ray.

4. Coarctation of the aorta.

a. Absent femoral pulse.

b. Late systolic murmur.

c. Decreased blood pressure in lower extremities.

d. Medical diagnosis: x-ray.

5. Tetralogy of Fallot.

a. Acute hypoxic/cyanotic episodes.

b. Limp, sleepy, exhausted; hypotonic extended position—postepisode.

c. Medical diagnosis—cardiac catheterization.

6. Transposition of the great arteries.

a. Cyanotic after crying or feeding.

b. Progressive tachypnea—attempt to compensate for decreased [latex] PaO_2 [\latex], metabolic acidosis.

c. Heart sounds vary; consistent with defect.

d. Signs of CHF.

e. Medical diagnosis—cardiac catheterization, x-ray, ECG.

D. Analysis/nursing diagnosis:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Fluid volume excess related to persistent fetal circulation, structural abnormalities.

2. Impaired gas exchange related to abnormal circulation, secondary to pathology.

3. Altered nutrition, less than body requirements, related to exhaustion, dyspnea.

E. Nursing care plan/implementation:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Goal: minimize cardiac workload.

a. Minimize crying—snuggle; pacifier—to meet psychological needs.

b. Keep clean and dry.

2. Goal: maintain thermal stability—to reduce body need for oxygen.

3. Goal: prevent infection.

a. Strict aseptic technique; standard precautions.

b. Hand washing.

4. Goal: parental emotional support.

a. Encourage verbalization of anxiety, fears, concerns.

b. Keep informed of status.

5. Goal: health teaching—explain, discuss:

a. Diagnostic procedures.

b. Treatment procedures.

c. Basic care modalities.

6. Goal: promote bonding. Encourage parents to participate in infant care, as possible.

7. Medical-surgical management: surgical intervention/repair of congenital cardiac abnormality.

F. Evaluation/outcome criteria:

1. Experiences no respiratory distress in immediate postnatal period.

2. Completes transfer to high-risk center without incident, if applicable.

3. Surgical intervention successful, where applicable.

III. DISORDERS AFFECTING FLUID-GAS TRANSPORT: hemolytic disease of the newborn

A. Rh incompatibility

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Pathophysiology.

2. Etiology.

3. Assessment:

a. Prenatal—maternal Rh titers, amniocentesis.

b. Intrapartum—amniotic fluid color:

  • Straw-colored: mild disease.
  • Golden: severe fetal disease.

c. Direct Coombs’ blood test; positive test demonstrates Rh antibodies in fetal blood.

4. Nursing care plan/implementation—exchange transfusion:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

a. Goal: health teaching.

  • Explain purpose and process to parents:

(a) Removes anti-Rh antibodies and fetal cells that are coated with antibodies.
(b) Reduces bilirubin levels—indicated when 20 mg/dL in term neonate and 15 mg/dL in preterm.
(c) Corrects anemia—supplies RBCs that will not be destroyed by maternal antibodies.
(d) Rh-negative type O blood elicits no reaction; maximum exchange is 500 mL; duration of exchange: 45 to 60 minutes.

b. Goal: minimize transfusion hazards.

  • Warm blood to room temperature, since cold blood may precipitate cardiac arrest.
  • Use only fresh blood—to reduce possibility of hypocalcemia, tetany, convulsions.
  • Give calcium gluconate, as ordered, after each 100 mL of transfusion.

c. Goal: prepare for transfusion procedure. Ready necessary equipment—monitor, resuscitation equipment, radiant heater, light.

d. Goal: assist with exchange transfusion.

  • Continuous monitoring of vital signs; record baseline, and every 15 minutes during procedure.
  • Record: time, amount of blood withdrawn; time and amount injected; medications given.
  • Observe for: dyspnea, listlessness, bleeding from transfusion site, cyanosis, cardiovascular irregularity or arrest; coolness of lower extremities.

e. Goal: post-transfusion care.

  • Assessment:

(a) Observe for: dyspnea, cyanosis, cardiac arrest or irregularities, jaundice, hypoglycemia; frequent vital signs.
(b) Signs of sepsis—fever, tachycardia, dyspnea, chills, tremors.

  • Nursing care plan/implementation:

(a) Maintain thermal stability—to reduce physiological stress, possibility of metabolic acidosis.
(b) Give oxygen—to relieve cyanosis.
(c) Keep cord moist—to facilitate repeat transfusion, if necessary.
(d) Maintain nutrition/hydration—feed per schedule.

5. Evaluation/outcome criteria:

a. Infant’s hemolytic process ceases; bilirubin level drops.

b. Infant makes successful transition to extrauterine life.

c. Infant experiences no complications of therapeutic regimen.

d. Infant shows evidence of bonding.

B. ABO incompatibility

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Pathophysiology—fetal blood carrying antigens A/B enters maternal type O bloodstream → antibody formation → antibodies cross placenta → hemolyze fetal RBCs. Note: less severe than Rh reaction.

2. Etiology:

a. Type O mother carries anti-A and anti-B antibodies.

b. Even first pregnancy is jeopardized if fetal blood enters maternal system.

c. Reaction possible if fetus is type A, type B, or type AB and mother is type O.

3. Assessment:

a. Jaundice within first 24 hours.

b. Rising bilirubin levels.

c. Enlarged liver and spleen.

4. Nursing care plan/implementation: Goal: reduce hazard to newborn.

a. Prepare for exchange transfusion with O-negative blood.

b. Phototherapy may be ordered if bilirubin is 10 mg/dL, and anemia is mild or absent.

c. Close monitoring of status.

d. Supportive care.

5. Evaluation/outcome criteria:

a. Infant responds to medical/nursing regimen.

b. Infant’s assessment findings within normal limits.

C. Hyperbilirubinemia

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Pathophysiology—bilirubin, a breakdown product of hemolyzed RBCs, appears at increased levels; exceeds 13 to 15 mg/dL. Bilirubin is safe when bound with albumin and conjugated by user for body excretion; danger is when unconjugated and deposits in CNS.

a. WARNING: There is no “safe” serum bilirubin level; kernicterus is a function of the bilirubin level and neonatal age and condition; poor fluid-and-caloric balance subjects the infant (especially the preterm infant) to kernicterus at low serum bilirubin levels.

b. Kernicterus—high bilirubin levels result in deposition of yellow pigment in basal ganglia of brain → irreversible retardation.

2. Etiology:

a. Rh or ABO incompatibility, during first 48 hours.

b. Resolution of an enclosed hemorrhage (e.g., cephalohematoma).

c. Infection.

d. Drug induced—vitamin K injection, maternal ingestion of sulfisoxazole (Gantrisin).

e. Bile duct blockage.

f. Albumin-binding capacity is exceeded.

g. “Breastfeeding jaundice” (e.g., pregnanediol in milk). Breastfeeding is not dangerous and not a cause of physiological jaundice.

h. Dehydration.

i. Immature liver (interferes with conjugation).

3. Assessment:

a. Jaundice noted after blanching skin to suppress hemoglobin color; noted in sclera or mucosa in dark-skinned neonates; make sure light is adequate; spreads from head down, with increasing severity.

b. Pallor.

c. Concentrated, dark urine.

d. Blood level determination—hemoglobin or indirect bilirubin (unconjugated, unbound bilirubin deposits in CNS).

e. Kernicterus—similar to intracranial hemorrhage.

  • Poor feeding or sucking.
  • Regurgitation, vomiting.
  • High-pitched cry.
  • Temperature instability.
  • Hypertonicity/hypotonicity.
  • Progressive lethargy; diminished Moro reflex.
  • Respiratory distress.
  • Cerebral palsy, mental retardation.
  • Death.

4. Analysis/nursing diagnosis:

a. Fluid volume (RBC) deficit related to hemolysis secondary to blood incompatibility.

b. High risk for injury (brain damage) related to kernicterus.

c. Altered thought processes (mental retardation) related to brain damage secondary to kernicterus.

d. Knowledge deficit (parental) related to infant condition.

5. Nursing care plan/implementation:

a. Medical management:

  • Prenatal—amniocentesis.
  • Postnatal—exchange transfusion, phototherapy.

b. Goal: assist bilirubin conjugation through phototherapy.

  • Cover closed eyelids while under light to protect eyes. (If Biliblanket is used, no need to cover eyes.) Remove eye pads when not under light (feeding, cuddling, during parental visits).
  • Expose as much skin as possible—to maximize exposure of circulating blood to light. Remove for only brief periods.
  • Change position q1h—to maximize exposure of circulating blood to light.
  • Note: any loose green stools as bile is cleared through gut; watch for skin breakdown on buttocks.
  • Monitor temperature—to identify hyperthermia. (Not necessary if using Biliblanket.)
  • Push fluids (to 25% more than average) between feedings—to counteract dehydration. Breast milk has natural laxative effects that help clear bile.

c. Goal: health teaching. Explain, discuss phototherapy, bilirubin levels, implications.

d. Goal: emotional support.

  • Encourage verbalization of anxiety, fears, concerns.
  • Encourage contact with infant.
  • Reassure, as possible.

6. Evaluation/outcome criteria:

a. Infant’s hemolytic process ceases; bilirubin level drops.

b. Infant makes successful transition to extrauterine life.

c. Infant experiences no complications of therapeutic regimen.

d. Infant shows evidence of effective bonding.

Health Promotion and Maintenance; Nursing Care of the Childbearing Family: Emotional Support of the High-Risk Infant

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

I. GENERAL ASPECTS

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

A. The high-risk infant has the same developmental needs as the healthy term infant:

1. Social and tactile stimulation.

2. Comfort and removal of discomfort (hunger, soiling).

3. Continuous contact with a consistent, parenting person.

B. Treatment for serious physiological compromise may result in:

1. Isolation.

2. Sensory deprivation or noxious stimuli.

3. Emotional stress.

II. ASSESSMENT—signs of neonatal emotional stress:

A. Does not look at person performing care.

B. Does not cry or protest.

C. Poor weight gain; failure to thrive.

III. ANALYSIS/NURSING DIAGNOSIS: sensory-perceptual alterations related to isolation in isolette, oxygen hood.

IV. NURSING CARE PLAN/IMPLEMENTATION:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

A. Goal: provide consistent parenting contact. Assign same nurses whenever possible.

B. Goal: emotional support.

1. Comfort when crying.

2. Provide positive sensory stimulation. Arrange time to:

a. Stroke skin.

b. Hold hand.

c. Hum, sing, talk.

d. Hold in en-face position (nurse looking into infant’s eyes).

e. Hold when feeding, if possible.

C. Goal: encourage parents to participate in care—to:

1. Reduce their psychological stress, anxiety, fear.

2. Promote bonding.

3. Reduce possibility of later child abuse (higher incidence of child abuse against children who have been high-risk infants).

V. EVALUATION/OUTCOME CRITERIA:

A. Infant demonstrates successful resolution of physiological problems.

B. Parents and infant evidence bonding.

C. Parents express satisfaction with care and result.

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Health Promotion and Maintenance; Nursing Care of the Childbearing Family: General Aspects: Nursing Care of the High-Risk Infant and Family

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

I. GENERAL OVERVIEW: The birth of a physiologically compromised neonate is psychologically stressful for both infant and family and physiologically stressful for the neonate. Effective, goal-directed nursing care is directed toward:

A. Minimizing physiological and psychological stress.

B. Facilitating/supporting successful coping or adaptation.

C. Encouraging parental attachment/separation/grieving, as appropriate.

II. ASSESSMENT—directed toward determining neonate’s present and projected status:

A. Determine neonate’s current physical status.

B. Identify specific status and diagnosis-related problems and needs.

C. Describe family psychological status, strengths, and coping mechanisms/skills.

D. Determine medical-surgical/nursing approach to problems—and prognosis.

III. ANALYSIS/NURSING DIAGNOSIS:

A. Parental anxiety/fear related to physiological compromise of neonate.

B. Self-esteem disturbance related to feelings of guilt or anger.

C. Ineffective individual coping related to severe psychological stress.

D. Knowledge deficit related to diagnosis, treatment, prognosis of infant.

E. High risk for altered parenting related to concern about infant.

IV. NURSING CARE PLAN/IMPLEMENTATION:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

A. Goal: preoperative and postoperative care.

1. Maintain/improve physiological stability.

a. Temperature stabilization—keep warm.

b. Oxygenation:

  • Position.
  • Administer oxygen, as ordered or necessary.

c. Nutrition/hydration:

  • Administer/monitor IV fluids.
  • Oral fluids, as ordered.
  • Feed, as status permits.

2. Assist with diagnostic testing.

B. Goal: emotional support of parents.

1. Encourage exploring and ventilating feelings.

2. Involve parents in decision-making process.

C. Goal: health teaching.

1. Determine knowledge/understanding of problem.

2. Explain/simplify/clarify, as needed, physician’s discussions with parents.

3. Describe/explain/discuss neonate’s present status and any auxiliary equipment; teach CPR to family.

4. Refer, as needed, to hospital/community resources.

D. Goal: promote bonding. Encourage parental participation in care of the neonate.

V. EVALUATION/OUTCOME CRITERIA:

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

A. Parents verbalize understanding of relevant information; make informed decisions regarding infant care.

B. Parents demonstrate comfort and increasing participation in care of neonate.

C. Infant maintains/increases adequacy of adaptation to extrauterine life.

D. If relevant, parents demonstrate progress in grieving process.

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FURTHER READING/STUDY:

Resources:

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